Prolonged Risk of Suicide Reattempts in Patients with Alcohol Use Disorder and Acute Alcohol Use: A Register-Based Follow-Up Study (2010–2015)

OBJECTIVE@#This study aimed to clarify the role of acute alcohol use and alcohol use disorder in individuals exhibiting suicidal behaviors, including repetition of suicide attempt.@*METHODS@#Data pertaining to 691 suicide attempters who had visited an emergency center and had been followed-up from 2010 to 2015 were gathered. Participants were categorized into following three groups according to alcohol use pattern at the time of the suicide attempt: 1) suicide attempters with neither alcohol use disorder nor acute alcohol consumption (NAU), 2) suicide attempters who had used alcohol during the suicide attempt but did not have alcohol use disorder (AAU), and 3) suicide attempters with alcohol use disorder (AUD). Group comparisons and multivariate Cox proportional models for suicidal behavior were used for statistical analysis.@*RESULTS@#AUD have been shown to have lower lethality of suicide attempt but higher risk of suicide reattempts in the future. Furthermore, positive relationships between suicide reattempts and AUD persisted throughout the longer period than other groups.@*CONCLUSION@#Suicide attempters with AUD should be considered a high-risk group for suicide reattempts in future, and this group should be followed-up for a longer period with specialized care program.

The Characteristics of Child and Adolescent Suicide Attempters Admitted to a University Hospital / 정신신체의학

OBJECTIVES: The purpose of this study was to identify the differences of demographic and clinical characteristics between child-adolescents who received medical inpatient care and non-hospitalized adolescents after suicide attempts. METHODS: The study included 35 child-adolescents who were hospitalized (Admission group) and 114 child-adolescents who were not hospitalized (Non-Admission group) as a result of a suicide attempt from 2009 to 2015. We compared sociodemographic, clinical, and suicide attempt-related characteristics through a chi-square test and logistic regression analysis to evaluate the differences between the two groups. RESULTS: Child-adolescents of this study most commonly attempted suicide by poisoning, and for motivation of interpersonal problems. Admission group had significantly fewer attempts through injury by sharp objects (χ²=4.374, p=0.037) and attempted suicide with a higher chance of actually dying when compared to Risk-Rescue Rating Scale (t=1.981, p=0.049). In addition, Admission group had relatively common motivation for academic problems (χ²=12.082, p=0.001) and less motivation for interpersonal difficulties. (χ²=9.869, p=0.002) Psychiatric diagnosis at the time of visiting the emergency department showed higher rates of depression in the admission group than Non-Admission group (χ²=8.649, p=0.003). The results of logistic regression showed that depression affects hospitalization (OR=2.783, 95% CI 1.092–7.089, p=0.032). CONCLUSIONS: This study is meaningful in that it revealed the social and clinical characteristics of all child-adolescents who were hospitalized at a university hospital after attempting suicide. This study identified differences in motivation, methods, and psychiatric diagnosis of hospitalized adolescents and those who were not. Therefore, the results may help adolescent suicide attempters to get a discriminatory approach based on their admission.

Complementarity between SDQ-SR and MMPI-A in Assessing Adolescents with Internalizing Disorder : A Preliminary Study / 정신신체의학

OBJECTIVES: The aims of this study were to investigate the psychopathology in adolescents with internalizing disorder using the self-report version of Strengths and Difficulties Questionnaire (SDQ-SR) and the Minnesota Multiphasic Personality Inventory for adolescents (MMPI-A), and to explore the complementarity between these two inventories for diagnostic assessment. METHODS: Ninety-one patients aged 13–17 were divided into two groups by clinical diagnosis, 44 with internalizing disorder and 47 comparison group with other disorders. The data of SDQ-SR and MMPI-A completed by them were analyzed for the ability to predict internalizing disorder. RESULTS: The logistic regression analysis revealed that diagnostic predictability increased by 2.27 times with every 1 point of SDQ-SR emotional symptom score increment. Comparison of ROC curves for internalizing disorders showed that the SE and SP of SDQ-SR emotional symptom with score over 4 was 88.94 and 78.72, respectively. For A-anx of MMPI-A with score over 56, SE and SP was 77.27 and 74.47, respectively. However, combination of these scales could not enhance the predictability of diagnostic classification more than that of SDQ-SR emotional symptom alone. CONCLUSIONS: Emotional symptom scale of SDQ-SR and A-anx, A-aln, A and INTR of MMPI-A should be important subscales for diagnosing the internalizing disorder of adolescents, however, which needs to be examined further with a larger sample size including normal control group.

The Role of Uncontrolled Eating and Screen Time in the Link of Attention Deficit Hyperactivity Disorder with Weight in Late Childhood

OBJECTIVE: The aim of this study was to examine the mediating roles of uncontrolled eating and sedentary behaviours in the link of attention deficit hyperactivity disorder (ADHD) and weight. METHODS: A total of 352 children in fifth and sixth grade participated in the present study by completing the self-rated Three-Factor Eating Questionnaire and Children of Alcoholics Screening Test during regular classes. An additional questionnaire completed by their parents provided information about the children's ADHD and emotional symptoms, sedentary behaviour based on screen time, and parental variables. The questionnaires were surveyed within one week after their schools' annual physical check-up. RESULTS: Hierarchical regression analyses revealed that uncontrolled eating was complete mediator in association between ADHD symptoms and body mass index (BMI) for boys, incomplete mediator for girls. However, screen time had no significant effect on the ADHD symptoms-BMI link for both gender. CONCLUSION: The findings of this study suggest that gender specific intervention programs may be need to help eating behaviour in children with ADHD and overweight.

Gender Differences in the Effect of Alcohol Use on Intent and Lethality of Suicidal Attempts / 정신신체의학

OBJECTIVES: The aim of this study was to clarify the role of alcohol use disorders and acute alcohol consumption in suicide attempts by gender. METHODS: Data of 1,152 suicide attempters(487 males and 742 females) who had visited an emergency center was gathered. Suicide attempts were categorized into three groups according to alcohol use: an alcohol use disorder group(AUD), an acute alcohol use group(AAU), and a no-alcohol use group(NAU). The intent and lethality of suicide attempts were evaluated by Suicidal Intents Scale and Risk-Rescue Rating Scale. RESULTS: For Suicidal Intents Scale score, the male AUD group revealed a significantly lower mean score than the male AAU one. However, there were no statistically significant differences for female subjects across subgroups. With regard to the Risk-Rescue Rating Scale score, there were no significant differences for males, while the AUD group showed both the lowest highest rescue scores and lowest risk-rescue scores within female groups. CONCLUSIONS: AUD in females was more likely regarding impulsive suicide attempts with high rescue chances. Consuming alcohol might have different effect on suicide attempts by gender and our study shows that alcohol use is an important risk factor according to gender, particularly with regard to female suicide attempts.

Symptomatic and Clinical Profiles Across Motoric Subtypes in Delirium / 정신신체의학

OBJECTIVES: To investigate clinical and symptomatic differences among motoric subtypes of delirium. METHODS: A total of 256 patients referred to psychiatric consultation services for delirium due to general medical condition were assessed retrospectively. Motoric subtypes were determined according to Lipowski's criteria for hyperactive, hypoactive and mixed subtypes. All patients were evaluated according to Delirium Rating Scale-Revised-98(DRS-98-R) by trained psychiatrists to obtain symptomatic profiles of delirium. RESULTS: Hyperactive subtype were 50.8%(n=130), mixed 46.1%(n=118) and hypoactive 3.1%(n=8). Hyperactive patients were younger than mixed subtype(69.62±13.976 vs. 73.97±11.569, p=0.022) and received antipsychotics to manage symptoms of delirium more frequently(83.8% vs. 57.6%, p<0.001). Hyperactive patients had higher DRS-R-98 scores on both noncognitive(7.14±3.543 for hyperactive, 5.62±3.279 for mixed subtype) and cognitive subscales(10.00±3.574 for hyperactive, 6.38±2.875 for hypoactive, 7.43±3.771 for mixed subtype, p<0.001). CONCLUSION: We demonstrated that clinical and symptomatic profiles were different across motoric subtypes in delirium. Diagnostic and therapeutic approach should be made differently according to motoric subtypes of delirium and special attention is needed not to underestimate or delay treatment in specific motoric subtype of delirium.

Psychometric Properties of the Self-Report Version of the Strengths and Difficulties Questionnaire in Korea

OBJECTIVE: To examine the reliability and validity of the self-report Korean version of Strengths and Difficulties Questionnaire (SDQ-Kr) in the community sample. METHODS: The SDQ-Kr was administered to a large sample of school children and adolescents (n=2814) and youth attendees of a psychiatric clinic (n=385) aged 11-16 years. To examine temporal stability, the same questionnaire was administered to a subsample of 167 school youths five to six weeks after the initial assessment. To examine the reliability, we calculated Cronbach's alpha coefficients for internal consistency and Pearson's correlations for test-retest stability. In order to evaluate the factorial structure of the SDQ-Kr items, we conducted an exploratory factor analysis (EFA) with varimax rotation. Finally, discriminant validity was examined by using receiver operating characteristic (ROC) curves employing the area under the curve (AUC) as an index of discriminant ability. RESULTS: Although the internal consistency of some subscales of the SDQ-Kr was somewhat less satisfactory (alpha coefficients; 0.28-0.54) than the English original, coefficients for the total difficulties scores approached sufficient levels (coefficients; 0.69). Other psychometric properties including discriminant validity (AUC for total difficulties and four subscales >0.7) were comparable to those obtained in other language studies. CONCLUSION: The self-report SDQ-Kr exhibited a low level of reliability, indicating that some items need to be further evaluated and revised to improve the psychometric properties. We suggest that the total difficulties score could be used with more confidence for screening possible mental health problems in youths.

Agreement between Parent and Teacher Reports in Clinical Setting : Comparing SDQ-Kr with K-CBCL

OBJECTIVES: The aims of this study were to examine agreement between parent and teacher ratings of the Korean version Strengths and Difficulties Questionnaire (SDQ-Kr) for the children's psychopathology and to determine whether it is effective in diagnostics as the Korean version of Childhood Behavior Checklist (K-CBCL). METHODS: SDQ-Kr and K-CBCL were completed by parents and teachers of 165 children aged 6-12 years. The clinical diagnosis was made by a child and adolescent psychiatrist who did not have knowledge of the outcome. Spearman's correlations were computed for associations between parents' and teachers' ratings on a subscale level. The Mann-Whitney U test was performed for the influence of child's age and sex on the results. Finally, AUC values were calculated for the diagnostic capacity and the difference between informants was tested using the z test. RESULTS: High correlations were observed between parents' and teachers' SDQ-Kr on every scale. Parents were more sensitive to emotional symptoms of girls, while teachers appeared to be more responsive to externalized symptoms of boys, inattention-hyperactivity of young children, and emotional symptoms of seniors. Parents' SDQ-Kr demonstrated the highest prediction of attention-deficit hyperactivity disorder. CONCLUSION: Teachers' SDQ-Kr can be used in identification of child psychopathology when parents are absent or when their reliability is considered low.

Alcohol Dependence, Mortality, and Chronic Health Conditions in a Rural Population in Korea

To determine the effects of excessive drinking and alcohol dependency on mortality and chronic health problems in a rural community in South Korea, this study represents a nested case-control study. In 1998, we conducted the Alcohol Dependence Survey (ADS), a population survey of a village in Korea. To measure the effects of alcohol on chronic health conditions and mortality over time, in 2004, we identified 290 adults from the ADS sample (N=1,058) for follow-up. Of those selected, 145 were adults who had alcohol problems, either alcohol dependence as assessed in the ADS by the Severity of Alcohol Dependence Questionnaire (N=59), or excessive drinking without dependency (N=86). Further 145 nondrinkers were identified, matching those with alcohol problems in age and sex. We revisited the village in 2004 and completed personal interviews with them. In multivariate logistic regressions, the rates of mortality and morbidity of chronic health conditions were three times greater for alcohol dependents compared with the rate for nondrinkers. Importantly, however, excessive drinking without dependency was not associated with the rates of either mortality or morbidity. Future investigations would benefit by attending more specifically to measures for alcohol dependence as well as measures for alcohol consumption.

A Prospective Study on Changes in Health Status Following Flood Disaster

OBJECTIVE: We examined changes in general health status, the prevalence of depression and post-traumatic stress disorder (PTSD) symptoms, and the existence of pre-trauma contributing factors in an agricultural population following a massive flood. METHODS: Eighty-three of 160 residents of Garisan-ni, Inje-gun, Gangwon-do, were assessed using the Korean version of the 36-Item Short-Form Health Survey (SF-36-K) between April and June 2006, just prior to a massive flood. Among those initially assessed, 58 residents were available for follow-up 18 months after the flood. Participants completed the SF-36-K, Beck Depression Index (BDI), Minnesota Multiphasic Personality Inventory (MMPI)-PTSD, and the Korean version of the Impact of Event Scale-Revised (IES-R) to detect depression and PTSD. Trauma experiences were also assessed. Factors related to changes in health status were then analyzed. RESULTS: SF-36-K total scale scores decreased significantly, suggesting a significant reduction in health-related quality of life. The largest reductions were noted in physical and social functioning. Fifty-three percent of the subjects were at least mildly depressed, and 17% had severe depression. In addition, 22% had PTSD on both the IES-R and MMPI-PTSD. Factors that contributed to the deterioration of health status following the flood were the number of disaster events and existence of depression (as assessed by the BDI). CONCLUSION: The flood was found to lead to deterioration of health status and to provoke depression and PTSD among the agricultural population in the mountainous region. We suggest that the number of disaster event experiences and existence of depression contriuted to changes in health status after the flood.

The Korean Practice Parameter for the Treatment of Pervasive Developmental Disorders: Development and Implications

The new research data and rapid development of psychotropic drugs over the past few years have warranted the development of clinical practice guidelines for managing pervasive developmental disorder(PDD). These guidelines are urgently needed due to the recent changes in social circumstances and clinical situations in Korea. Despite the many limitations and problems surrounding the development of these guidelines, the Korean Academy of Child and Adolescent Psychiatry(KACAP) has decided to develop the Korean Practice Parameters for the Treatment of PDD. The goal, basic principles, organization, and implications of this development project are introduced in this special paper. We expect these practice parameters to be a useful reference not only for child psychiatrists and other healthcare professionals in clinical practice, but also for the autistic patients themselves and their caregivers. The practice parameters shall be revised and improved in the near future.

The Korean Practice Parameter for the Treatment of Pervasive Developmental Disorders: Clinical Manifestation, Epidemiology, Course, Causes, and Comorbidity

Pervasive developmental disorders are characterized by lifelong impairments in fundamental social and/or communication skills and by the presence of seemingly purposeless and repetitive behaviors, interests, or activities. A number of possible biological etiologies, including genetic, structural and functional brain abnormalities, have been identified in patients with pervasive developmental disorders. In addition, clinicians should take the possibility of comorbid psychiatric conditions into consideration when making the differential diagnosis of pervasive developmental disorders.

The Korean Practice Parameter for the Treatment of Pervasive Developmental Disorders: Diagnosis and Assessment

Multiple areas of development are affected in pervasive developmental disorders(PDD), and assessments of various aspects of behavior and development are essential for diagnosis. The object of this review is to provide the practical guidelines for the assessment of core features of PDD, including abnormalities in communication, social interaction, and repetitive and stereotyped behavior. It covers the issues of differential diagnosis within and outside the PDD category, standardized diagnostic tools, assessment of intellectual and language functions, and the early diagnosis of PDD in infancy. This guideline also stresses the process of medical and neurological evaluation for proper diagnosis of PDD.

The Korean Practice Parameter for the Treatment of Pervasive Developmental Disorders: Pharmacological Treatment

The objective of this review is to establish practice parameters for pharmacological treatment of children and adolescents with pervasive developmental disorders. We performed a detailed review of the literature, including a wide range of controlled clinical trials, open trials, case reports, and side-effect profiles of related drugs. Few medications have a treatment indication for pervasive developmental disorders, and few studies with well-controlled methodology are available for evaluating treatment results. Pharmacological treatments focus on associated target symptoms because symptom reduction may improve educational and social ability and enhance quality of life. Well-controlled trials have been conducted for some SSRI(selective serotonin reuptake inhibitor) antidepressants, risperidone, and methylphenidate, and showed reduction of some target symptoms. Since the medications are not specific to autism and do not treat core symptoms of the disorder, their potential side effects should be carefully considered. Family education is necessary to give proper information on target symptoms, limitation of drug treatments, and risks.

The Korean Practice Parameter for the Treatment of Pervasive Developmental Disorders: Non-Pharmacological Treatment

Practice parameters for non-pharmacological treatment of children and adolescents with pervasive developmental disorders are based on the scientific literature for evidence-based practices. Appropriate educational and behavioral interventions are important in improving the long-term outcome in pervasive developmental disorders. Early and sustained intervention appears to be particularly important. The goal for interventions is to gain pragmatic skills for verbal communication, playing with peers, daily living routines, self-management, and social adaptation. Appropriate involvement and collaboration with parents and family are essential for well-functioning intervention programs. The life-long nature of autism implies that the clinician should maintain an active role in long-term treatment planning and family support. Vocational training and training for more independent living are important for adolescents with autism. Professionals should be knowledgeable about local and national resources and opportunities for family support as well as support of the individual.

Characteristics of Attention in Children with Post-Injury Attention-Deficit Disorder and Developmental Attention-Deficit Hyperactivity Disorder / 신경정신의학

OBJECTIVES: Children with post-injury attention deficit disorder (ADD) exhibit deficiencies in academic functioning, social skills, and self-control, that are comparable to developmental attention-deficit hyperactivity disorder (ADHD). The similarities and differences of the two conditions have to be studied because some children with traumatic brain injury have shown premorbid ADD and seem to be less responsive to psychostimulants. METHODS: Characteristics of cognition and attention of post-injury ADD (n=12) and developmental ADHD (n=12) boys were investigated by administering KEDI-WISC and Visual and Auditory TOVA. RESULTS: No differences in KEDI-WISC subtests were found between two diagnostic groups. Post-injury ADD boys show lower commission error (lower impulsivity) in visual and auditory TOVA, and lower variability of reaction time (higher information-processing consistency) in auditory TOVA than developmental ADHD boys (p<0.05, p<0.01). CONCLUSION: Post-injury ADD and developmental ADHD are different in their attention components suggestively, which warrants further study for differential diagnosis and proper treatment.

The Development of a Korean Version of the Strengths and Difficulties Questionnaire / 신경정신의학

OBJECTIVES: This study aims to develop a Korean version of the Strengths and Difficulties Questionnaire (SDQ-Kr). METHODS: The Strengths and Difficulties Questionnaire (SDQ) is a brief behavioural screening questionnaire that can be completed by the parents within 5 minutes and used to assess the psychopathology (prosocial behaviour, hyperactivity, emotional problems, conduct problems, and peer problems) of 4-16 year olds. The SDQ was translated into Korean, retranslated back to English, and corrected after discussion with the original developer and trial test. The reliability and validity of the SDQ-Kr was evaluated by working with 347 parents of nonclinical (n=98), pediatric outpatient (n=92), and psychiatric outpatient (n=157) children. RESULTS: Working with 62 parents of nonclinical children, the test-retest reliability of 5 subscales of SDQ-Kr was 0.94-0.84 (p<0.01). For 190 nonclinical and pediatric children, internal consistency of 5 subscales of SDQ-Kr was 0.80-0.50 (Cronba-ch's alpha). Factor analysis generated the five identical factors with the five subscales explaining 49.5% of total variance. For 347 children of nonclinical, pediatric, and psychiatric group, ANOVA showed that any two among the three groups was significantly different in subscales and total difficulties scores, except between pediatric and psychiatric children in emotional problems subscore (p<0.01). The discriminating rate among three groups was 75.5% in discriminant analysis. CONCLUSIONS: The Korean version of SDQ shows very similar psychometric performance to the original SDQ developed by Goodman. This study gives evidence of the usefulness of the SDQ-Kr as a promising screening instrument for epidemiological research and clinical purposes.

Risk and Protective Factors in the School Adjustment of Socially Bullied Secondary Students / 신경정신의학

OBJECTIVES: Although verbal and social bullying is more common than physical school violence among secondary students, it's harmful influences have been underestimated. It is essential to investigate the risk factors of clinically referred bullied children with school maladjustment and psychiatric symptoms and the protective factors of the non-referred resilient children despite of being bullied for developing the anti-bullying program. METHODS: The questionnaire asking frequency and severity of being bullied socially, Kovacs Children's Depression Scale, and Piers-Harris Children's Self-Concept Scale were administered to 128 secondary students in Wonju and 65 secondary students referred for their school maladjustment to psychiatric outpatient clinic. Fifty-five students (boys: 19, girls: 36) of bullied non-clinical group and 42 students(boys: 21, girls: 21) of bullied clinical group were compared with their scores of being bullied, depression and self-concept, and the gender difference in those comparisons was studied. RESULTS: More negative self-concept and poorer relationship with family were noticed in the clinical group, despite of no difference in being-bullied score and depression score between the two. Five subscales of the self-concept, behavior, academic status, appearance, popularity and happiness were more negative in clinical group, but not with anxiety subscale. With coping strategy, there was no difference. Multiple regression analysis showed that depression score was accountable by negative self-concept only in the clinical group, and by appearance and anxiety in non-clinical group. And gender differences were not found in those all variables. CONCLUSION: It is suggested that the risk factor for school maladjustment occurred after being bullied socially is the negative self-concept, and the protective factor for resilient children is the supportive relationship within family.

Efforts and Therapeutic Factors of Short-term Token Economy for Negative Symptoms of Schizophrenic In-patients / 신경정신의학

OBJECTIVE: The negative symptoms of schizophrenia usually are not responsive to drug therapy to persist and make schizophrenics more difficult in their rehabilitation. The authors investigated the therapeutic effect of token economy(TET) for negative symptoms of schizophrenic patients, and attempted to develop a TET program f3r psychiatric wards in general hospital. METHODS: Negative subscale of PANSS was rated for 35 schizophrenics with negative symptoms as their main problems before and after short-term TET(less than 3 months). Therapeutic factors were identified by comparing patient and program variables between the achieved and the non-achieved group of each level of target behaviors. RESULTS: 1) Subtotal of negative subscale of PANSS was decreased from 31.57+/-4.32 at baseline to 20.66+/-4.63 artier treatment. With TET, symptoms of difficulty in abstract thinking' and 'stereotypic thinking' were less responsive than the other 5 items of the scale Also the dose of antipsychotics prescribed was reduced to 291.21+/-287.74mg/day from 487.58+/-372.79mg/day. 2) The achievement rate of level I (self-help) was 75%, level II (ward-activity) 78%, and level III (social activity/occupation) 68%, resulting in average 74% for all target behaviors. 3) On level II, dose of antipsychotics was lower, and on level III, number of admission was lower and female sex was more frequent in achieving patient group than nonachieving group. The rate of achievement was higher in case of special flood, reception, and outing with family applied as a reinforcer on level I, and reception on level II . CONCLUSION: These results showed that TET was effective for schizophrenic patients with negative symptoms in psychiatric ward. Further investigations to refine the individual program of TET will be needed far enhancement of it s therapeutic efficacy and smart application of it.

Preliminary Study for the Effect of No-smoking on Antipsychotics, Benztropine and Propranolol Dosage for Re-admitted Psychotic Patients / 신경정신의학

This study was designed to investigate the effect of no-smoking on the pattern of medication for 30 re-admitted psychotic patents in the no-smoking(smoking-prohibited) ward, who had been admitted and medicated previously in the smoking (smoking-allowed) ward, in Wonju Christian Hospital, by comparing daily mean dosage of antipsychotics, benztropine mesylate, and propranolol administered in smoking state and in no-smoking state of the same patients. The results were as follows: 1) The mean hospital stay was reduced to 46.0 days in no-smoking ward compared to 61.1 days in smoking-allowed ward. This means mean admission period was reduced significantly(p<0.05) and over two thirds of all subjects experienced reduction of hospital stay from 2 days to 92 days. 2) A statistically significant difference was fecund in the dosage of antipsychotics in all subjects. Calculated in terms of chlorpromazine equivalent, the daily mean was 296.8+/-180.7mg in no-smoking state, and 395.0+/-232.2mg in smoking state(p<.01), 3) In schizophrenics(n=13), the daily mean dosage of benztropine mesylate was 0.56+/-.62mg in no-smoking state and 0.14+/-0.21mg in smoking state, showing a significant difference(p<.05). In bipolar group, the mean dosage in no-smoking ward was also smaller than in smoking ward, though not significant. 4) The difference of the daily mean dosage of propranolol between two states was not significant. In conclusion, in no-smoking state psychotic patients required less hospital stays and significantly lower dosage of antipsychotics, and the schizophrenics required significantly higher dosage of benztropine mesylate for extrapyramidal symptoms. The authors suggest that psychiatric patients should be encouraged to stop smoking and recommend that psychiatrists monitor smoking state of their psychotic patients for proper and efficient drug therapy.